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Over the next four years financial reality will hit a bloated NHS, with real spending due to fall by 20%. Among the first casualties will be the myriad of quangos that sprung up under the previous government, from the National Patient Safety Agency to the Advisory Board on the Regulation of Homeopathic Products. But NICE has escaped the carnage, emerging emboldened. Soon, it must take ownership for addressing the emerging pressures in the post-reform NHS.

In a decade, NICE has become part of the clinical landscape and gradually won over many of its critics. But it must not lose its potency and meld into the status quo it was created to challenge. Some of its guidelines now look eerily similar to those produced by specialist societies that rely heavily on commercial sponsorship. It would be an irony if GPs had to revert back to practising one-to-one evidence-based medicine because the quality of clinical guidelines became suspect.

Political promises must also be addressed. In its election manifesto, the Conservatives promised to ring-fence spending on high-cost cancer drugs by setting aside a budget of £200m. More recent figures have been in the region of £50m, but it is difficult to reconcile NICE's rationing role with ring-fencing of drugs regardless of their cost. The move undermines the basis for all the institute's decisions – the quality-adjusted life-year, or QALY – by playing with the numbers to make it easier to recommend the drugs that will extend the lives of dying patients.

NICE has shown it is willing to compromise on its own rules. Media protests over decisions to reject anti-cancer drugs forced it to review its position that ‘a QALY is a QALY is a QALY' – that is, that the value of a year of life gained remains the same whatever a patient's age or proximity to death. Use of QALYs forms part of NICE's fundamental tenet of cost-effectiveness; adjusting them for societal preferences is only one step from allowing individuals to apply their own weights to them.

Use of the QALY is further challenged by the move to a market-based NHS, particularly by plans for patients to hold personal health budgets and by Government pronouncements that GPs should be patients' ‘friends' in offering them the treatments they want. Achieving patient-centred care through a market mechanism means value lies in the eye of the beholder and this is difficult to reconcile with the standardised QALY approach.

People want more freedom to make their own judgments on the value of drugs and make their own adjustments to the QALY, as has happened with cancer. The passing of ‘big government' will frighten some of those for whom paternalism has become the norm. But NICE's future may be as a tariff-setting body, informing the decisions patients make just as they do in other aspects of their lives.

The NHS has experienced 13 years of single-party administration and NICE was itself a creation of this previous ideology. It should not make the mistake of underestimating how different things can be: a very different approach to policy is now being taken.

If NICE doesn't actively adapt to this new reality it risks becoming an anachronism – unable to match the aspirations of modern society.

Dr Rubin Minhas is a GP in Medway, Kent, clinical director of BMJ Evidence Centre and an adviser to NICE. These are his personal views.